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Natural languages are wondrous tools for communicating about experience and therefore for dealing with it buy levitra soft 20 mg without a prescription. As John Austin pointed out in proposing speech act theory purchase levitra soft 20mg free shipping, words carry meaning many ways generic levitra soft 20mg without a prescription. Imagination and emotion are two aspects of meaning which are among the orphans of formal logic levitra soft 20 mg overnight delivery. The way imaginative structures work in cognition has recently been the focus of intense investigation and discussion buy generic levitra soft 20 mg online. Although emotion and its connection to value is not entirely separable from imagination, the emphasis in this chapter is on imaginative cognition and its use in means/ends informal reasoning. Some aspects of a putative logic of emotion and values will also be sketched out toward the end of the chapter and in Chapter Five. Extensive work in cognitive linguistics by Eleanor Rosch, George Lakoff, Mark Johnson, Eve Sweetser and many others has uncovered an array of cognitive structures we use both colloquially and philosophically as tools to conceptualize the means/ends relationship. Some structures used imaginatively to cope with experience, including means/ends problems in medicine, are textured or radial categories (at times with fuzzy and/or overlapping boundaries), several different image schemas to be explicated below, metaphors and scenarios for event structure, cause and effect, means and ends, and acts and consequences. These structures enable us to associate particulars in categories without imposing a straitjacket of rigid inclusion criteria over all individual differences. Fuzzy and partially portable boundaries allow variable splitting and amalgamation of continua into manageable numbers of parts for varying purposes. Imaginative metaphors grow organically by describing the relatively distant and strange in terms of the close up and familiar. Because such descriptions are recog- nized not to be literal, multiple metaphors depicting events, cause and effect, and various cognitive models of goals such as "health" can coexist and contribute alternate perspectives without being mutually destructive. Most important for medicine are the partially metaphorical understandings of "health" and "disease" and narratives of helping, endurance and recovery which are built using these metaphors. Since understanding the semantic architecture of disease is so important as the cognitive background within which examples of means/ends reasoning used here work, the entire second chapter is devoted to that subject. In reviewing the broad imagistic and metaphorical structure underlying informal means/ends reasoning in medical care we need to highlight its two great divergences from formal logics. First, it is neither arbitrary, in the way that the axioms of different logical systems as well as the entailment rules can be arbitrary. Nor is it any unique privileged system grounded eternally in a realm of reason and taking no measure of the human. It has grown organically out of our fundamental biological and existential embodiment. We cannot simply set up rules for understanding and reasoning by fiat, nor have we inherited them for all eternity. While cognitive structures are somewhat flexible, it is not possible to depart radically from existing ones. The basic bodily predicament into which we have been thrown is the only starting point, the only jumping off place from which the rest of experience can make any sense and to which it can be referred. We are incarnated in our ways of thinking and it is from within them, not outside of them, that our degrees of freedom will be found. Empirical thinking has slack, redundancy, room for ambiguity and even for multiple changing evaluations. There are no absolute rules forcing us to ride roughshod over variations and subtleties. Such empirical and informal reasoning does more justice to many clinical encounters than do formal rules, which try to treat medicine like chess. Categories Individual entities, as we choose to define and pick them out, are considered for different purposes as belonging in various types of groups. Classical categories of these individuals are sets defined by necessary and sufficient conditions for membership. Individuals possessing the specific required features or properties which characterize a category are conceived of as members of that category. Such categories are metaphorically conceived to be containers with rigid boundaries having inclusion or exclusion as an all or nothing matter. The essence of an individual, 14 CHAPTER 1 defined by the necessary and sufficient conditions, is all that counts in reasoning about that individual as a set member.

Commonly Used Drug Therapies The tricyclic antidepressants most often implicated in drug-induced injury in the elderly include the older A group of drug-related medical problems has been tertiary amines amitriptyline order levitra soft 20mg otc, doxepin 20mg levitra soft fast delivery, and imipramine buy cheap levitra soft 20mg on-line. Instead buy levitra soft 20mg without a prescription, a new drug is pre- take inhibitors (SSRIs) as well as with the older hetero- scribed with the patient now placed at the additional risk cyclic antidepressants buy levitra soft 20mg otc. Indeed, one of these studies59 of developing yet another drug-related problem as a found that depressed older patients appeared to be at result of the new drug therapy. There are numerous increased risk of falls even before antidepressant therapy examples of prescribing cascades: the use of nonsteroidal had been started. In fact, anticoagu- condition, when they may well be amenable to appropri- lation in patients with chronic nonrheumatic AF can ate diagnosis and therapeutic action. An overstatement that an older patient is often tempered by concerns about the 70 J. Rochon risk of bleeding, despite the fact that these patients may Prostaglandins also mediate a range of effects that have the most to gain from anticoagulant therapy. The protect the mucosa of the stomach and duodenum from extent of anticoagulation, as reﬂected by the interna- injury; these include the inhibition of acid secretion, an tional normalized ratio (INR), is the dominant risk factor increase in mucous secretion and bicarbonate, and for hemorrhagic complications. When the biosyn- presented conﬂicting ﬁndings on whether there is a thesis of prostaglandins is impaired by NSAIDs, this can greater risk of anticoagulant-induced hemorrhage in lead to impaired mucosal defense; acid and peptic activ- elderly patients, which may be explained to a large extent ity can then produce ulcers. A meta-analysis of epidemi- by differences in treatment setting and in the attention ologic studies investigating the association between given to monitoring. Risk The risks associated with NSAID use in the elderly of anticoagulant-related bleeding appears to be reduced emphasize the need for careful monitoring of patients when expert consultation is provided at the start of anti- with risk factors for NSAID-associated nephrotoxicity coagulant therapy and when patients are monitored in and gastropathy. The lowest feasible the optimal target INR, and the use of potentially inter- dose should be prescribed for the shortest time necessary acting medications are the most important strategies for to achieve the desired therapeutic effect. Because of the reducing the risk of bleeding complications in older iatrogenic nature of these disorders, the best treatment patients. For example, nonacetylated salicylates may be a safer Nonsteroidal Anti-Inﬂammatory Drugs alternative to NSAIDs. Another effective analgesic Nonsteroidal anti-inﬂammatory drugs (NSAIDs) are choice is acetaminophen. One study comparing the anal- very widely used in the management of arthritis; because gesic effects of acetaminophen (4 g/day) to ibuprofen the prevalence of degenerative joint disease increases (1. The acetaminophen compared to those given NSAID NSAIDs encompass several different chemical entities, therapy. It is most patients; its toxicity is increased in the presence of important to consider, however, that prostaglandins also hepatic insufﬁciency, heavy alcohol intake, or fasting. For example, inhibitors) were approved for use in North America for prostaglandins maintain renal blood ﬂow and glomerular arthritis treatment: celecoxib and rofecoxib. Under such orrhage and reduced renal function, have been associated conditions, vasodilatory renal prostaglandins mitigate with use of Cox-2 inhibitors. In this way, NSAIDs, Cox-2 inhibitors are less likely to produce gas- renal perfusion is maintained, preventing prerenal trointestinal ulcers, although ulcers do occur and this azotemia and eventual ischemic damage to the kidney. A prospective study of elderly effect of rofecoxib relative to indomethacin on glomeru- residents of a large long-term care facility who were lar ﬁltration rates in 75 patients between the ages of newly treated with NSAID therapy demonstrated that 60 and 80. These higher NSAID dosage and concomitant loop diuretic ﬁndings indicate the need for caution when prescribing therapy. Principles of Pharmacology 71 The Context of Adverse Drug Effects drug events (Table 7. Neuropsychiatric events (confu- sion, oversedation, delirium), falls, and hemorrhagic in Frail Elderly events were the most commonly identiﬁed preventable adverse drug events (Table 7. Of all types of therapeutic interven- tions, medications are the most commonly utilized in the have been developed and tested to reduce the risks of psychoactive drug use in the nursing home setting. The occurrence of adverse drug events that may be medication use has been utilized with success to improve preventable is among the most serious concerns regard- the quality of drug prescribing, speciﬁcally in regard to ing medication use in the nursing home setting. Few antipsychotic medications and long elimination half-life benzodiazepine therapy. A retrospective review of incident reports relating to found to be the next leading cause of adverse drug events adverse and unexpected events in one academically afﬁl- in long-term care facilities. Concerns have been raised iated, 700-bed long-term care facility identiﬁed 50 reports regarding the quality of anticoagulant use in the nursing 79 home setting,86 with evidence for both undertreatment of adverse drug reactions over a 1-year period. Skin rashes were the most frequently reported events, and and poor control of INR. A more systematic approach to antibiotics were the most commonly implicated medica- decision making regarding the use of warfarin for stroke tion category.

Hahne- mann did not specify whether it was necessary to stimulate spiders to obtain a stronger extract of Tarantula buy levitra soft 20 mg fast delivery. Coming on top of the law of similarity and that of dilution discount levitra soft 20 mg with mastercard, the law of dynamization lodges homeopathy firmly in the realm of magic generic 20mg levitra soft, 28 And Then Came Hahnemann leaving the field of science for that of the rabbit’s foot and the four-leaf clover proven 20mg levitra soft. Spelling out his theory purchase 20mg levitra soft free shipping, Hahnemann posits the principle that every therapy must be adapted to the patient, that there is no standard remedy for a standard patient and that every treatment must be se- lected according to a list of criteria that to some extent "explain" the patient. Since each patient has a unique identity, the homeopath does not describe a disease, he describes symptoms and an individual. It is the convergence of the symptoms and the type of individual that deter- mines what should be prescribed. The medicine thus varies not only according to the symptoms (which would follow a certain logic) but according to equally important criteria that may be as different as the eye or hair color, body size and shape, sex, and temperament (carbonic, phosphoric, fluoric). Reliance on criteria like these when prescribing treatments has allowed the reintroduction today of abhorrent pursuits that really do not seem out of place the homeopathic galaxy: morpho- psychology, astrology and numerology. In 1810, Hahnemann happily published the homeopathic bible, The Organon of the Art of Healing, and declared: "I recognize as disciples only those who practice pure homeopathy and whose treatments are en- tirely free of any combination with those means that had been em- ployed up until now by the old medicine. In Octo- ber 1984, the Academy of Medicine declared that it was "inappropriate, given the current state of knowledge, for the Colleges of Medicine and Pharmacy to grant diplomas certifying therapies that are neither ac- cepted nor used by most of the medical profession". This declaration came on the heels of a recommendation by the National Council of the Order of Physicians demanding that alternative medicines "be tested according to criteria as severe as those to which the traditional diag- nostic and therapeutic methods are subjected". But after the European Parliament voted in 1992 to approve a rec- ommendation to introduce homeopathy into the university curricula, these fine resolutions evaporated. On December 15, 1997, the National Council of the Order of Physicians publicized a study produced by its committee on homeopathy. The report’s conclusions immediately elic- ited strong, mixed reactions from the medical profession, due to the timid wording adopted by the committee. Their conclusions make it clear that the committee members had conflicting opinions on the value of homeopathy. Even while the committee questioned its value, and recommended that the practice should be evaluated, they qualified it nevertheless as a therapy, and in lyrical terms — to the great satisfac- tion of its proselytes. Ideological lobbying had effectively taken over for industrial lobbying, and homeopathy — having achieved broad ac- ceptability despite the protests — has created a precedent for charla- tanesque practices, thus threatening the reliability of the medical pro- fession. Since then, it is easier to understand why the Order of Physicians does not try to set straight expert hucksters like Dr. The principle of similarity may not, in itself, deserve savage scien- tific opposition, even given Hahnemann’s fundamental approximations; 30 And Then Came Hahnemann the same cannot be said of the techniques of dilution and "succussion". The principle of Hahnemann Concentrations establishes a for- mula for diluting a given product. W ith 1 H C (a one-hundredth Hah- nemann dilution) we have one part of the specified substance in 100 parts of the final product. At 2 H C, it is diluted to one: ten-thousand; at 3 H C, it is one to a million, and so on. However, you cannot dilute an active agent infinitely without reaching a point where the quantity of agent in each bottle that you produce. The laws of chemistry set the limit of dilution at which some bottles will end up without one active molecule, and Avogadro, an Italian chemist who was a contemporary of Hahnemann, had already established the total number of molecules 4 contained in a given quantity of a corps. Under a monitor’s supervision, he ingested ten tubes (that is, 800 tablets) of Arsenicum album (the arsenic used by poi- soners) covering the entire range of dilutions common in this market (from 4 H C to 30 H C); and he did so without experiencing any toxic effect, nor indeed any noticeable effect at all. And just a few weeks ear- lier, two children playing at a major homeopathic laboratory had swal- lowed the contents of several tubes of homeopathic pills that had been "forgotten" in the wastebaskets; in that case, too, there was no discerni- ble effect on their health. Faced with such challenges to its credibility, homeopathy is con- tinually coming up with arguments to prove if not its good faith, then at least its effectiveness. For example, exploiting the ambiguity inher- ent in the law of similarity, homeopaths try to lend credibility to the hypothesis that homeopathic solutions act the same way as vaccines, by creating an immunity. Vaccination is practiced on subjects that are free of any sign of the disease in order to stimulate preemptively the production of antibodies — antibodies which, in the event the subject later comes into contact with the disease, will protect him. This is contrary to the law of similarity, which recommends prescribing "attenuated" sub- stances to individuals who are already suffering from the symptoms of the stated disease. Another way that certain homeopaths attempt to "legitimize" their work is by comparing the use of the homeopathic drugs with mithridatization* or de-sensitization, through the administration of infinitesimal doses of active substances. However, in the case of mith- ridatization, the toxic products are administered in gradually increased doses up until the level at which the toxicity should make the subject ill. Similarly, with de-sensitizing, increasing amounts of an allergen are administered in order to stimulate the production of antibodies, pre- ventively.

You will be very familiar with your material but do not assume that your audience shares your understanding; for example say what the "x" and "y" axes represent on a graph; explain the key to your histograms levitra soft 20 mg low cost. We would probably all like a pound for every slide or overhead that we have been shown in a scientific presentation that is impossible to see or interpret discount 20 mg levitra soft, for which the presenter apologises to the audience buy levitra soft 20mg without prescription. Why not make a new slide which summarises the point that the original was attempting to make? Consider varying the delivery mode Attention span is limited purchase levitra soft 20mg online, especially if your audience is sitting through a series of presentations order levitra soft 20mg amex. In a presentation lasting more than 15–20 minutes, it is worth thinking about switching modes of delivery – for instance, to use a video clip to illuminate a particular point which you wish to drive home. Think about the visual impact of being shown an operating technique, for instance, versus a verbal description of it. Or a real patient describing a condition they suffer from, versus your description of what such a patient might say. Don’t go over the top We have all been to presentations that were dazzling – dual projection, fancy animated PowerPoint slides, videoclips, etc. It may seem an obvious point, but the greater the number of modes of delivery, the greater the risk of technical failure. This is dealt with in more detail in Chapter 8, but remember that there will always be questioners who are trying to score points, gain attention, or display knowledge rather than genuinely trying to find out more about your work or ideas. If you know that there are areas in your presentation that may confound or compromise some of the evidence that you are presenting, address these in the body of your talk to pre-empt obvious points of attack from questioners. Remember that good research provokes as many questions as it answers and occasionally a member of the audience will ask the question that you had not thought of that will trigger your next research proposal. Doctors should not pretend that they know the answer to a patient’s question when they do not. Similarly, admit to your audience if you cannot answer one of its questions, agree to find out the answer and remember to follow it up. You can sometimes engage your audience more actively if you throw the question back. Look out for non-verbal communication How you check what the audience has understood from your talk is clearly difficult though not impossible. The questions that you are asked at the end of the talk may give you some insight into the level of comprehension. What is conveyed to you non-verbally from the audience during your presentation may be just as revealing. If you spot any such behaviour, either bring your talk to a conclusion or do something to wake up the audience, such as asking a question or telling an amusing anecdote. Conclusion There is real satisfaction to be had from giving a presentation that is well thought out, properly rehearsed, and confidently and enthusiastically delivered. Indeed, anything less indicates lack of 7 HOW TO PRESENT AT MEETINGS respect for your audience and will leave you feeling embarrassed and disinclined ever to repeat the experience. Abraham Lincoln said, memorably: ‘If I had six hours to chop down a tree, I should spend the first four hours sharpening the axe’. Take heart from the experience of most presenters which is that although they may feel very nervous beforehand, once started they actually enjoy the experience. There are few highs to be compared with knowing that your careful preparation paid off and you got it absolutely right. Summary • Presentation tends to be a one way communication process • Prepare your presentation well by understanding your audience, rehearsing your presentation, preparing prompt cards and checking the venue and equipment • Think of the content: describe the purpose of the talk, deliver the talk and summarise • The delivery of the presentation is important – think carefully about both verbal and non-verbal communication and visual aids References 1 Silverman J, Kurtz S, Draper J. Contrary to popular belief, good lecturers are not born with an innate talent to lecture, although some do have more confidence than others to speak in public; this is not synonymous with being able to deliver a good lecture. However, like everything else, it is a skill that can be learnt, just like inserting a central venous line. It requires practice, discipline and adherence to a reasonably strict set of guidelines. The two basic tenets of a good lecture are meticulous preparation, which takes time, and rehearsal. The invitation The first time you are invited to lecture will engender a number of emotions, pride, to why me? It is true to say that there are a minority of people who are quite unable to stand up and talk in front of an audience, and if you are one of these then say so immediately.